ANNEX "B-12"

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'4
EA*" APPLICATION FORM FOR CREDITING ACTIVITIES THAT DID NOT GO
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il •,
gal THROUGH THE CPD COUNCIL FOR ACCREDITATION

CPD COUNCIL OF/FOR

Part I. Personal Information

Name:

Profession: License No.:

Date Issued: Valid Until:

Residence Address:

Telephone No.: Fax No.:

Cellphone No.: E-mail Address:

Company Name (if employed): Position:

Company Address: Telephone No.:

Part II. Nature of CPD Programs

Informal (Professional
Formal Non-Formal Others
Work Experience)

Part III. Acknowledgment

I hereby certify that the above information written by me are true and correct to the best of my knowledge and
belief. I further authorize PRC and other agencies to investigate the authenticity of all the documents presented.

I am agreeing to the PRC Privacy Notice and giving my consent to the collection and processing of my
personal data in accordance thereto.

(Signature Over Printed Name)

Position

Date
Part IV. Assessment and Review
Regulation Division: Cash Division:
Assessed by : Amount : O.R. No.:
Date Date
Remarks : Issued by •
Part V. Action taken by the CPD Council

Approved Credit Units Granted:

Disapproved
Deferred pending compliance

Chairperson

Member Member

Date